Cervical dysplasia is a very common disorder that, unfortunately, affects a large number of patients. It is a pre-cancerous change of the cells that line the surface of the cervix. There are, however, preventative measures that a woman can take as well as treatments after a diagnosis.
Anatomy of the Cervix
The cervix is the lowest portion of the uterus and it opens into the vagina. It is covered by a tissue similar to that which lines the inside of your mouth. Near the opening of the cervix , there is a special area called the transformation zone that undergoes frequent cellular changes during a woman’s life. These changes make it the most susceptible area of the cervix to the effects of an infection with a virus known as HPV or Human Papilloma Virus which is the most common sexually transmitted infection in the world.
It is the exclusive cause of almost all pre-cancerous and cancerous changes of the cervix and studies indicate that by the age of 25, 80-85% of men and women are exposed to this infection. The reason that it is so common is because the infection has no symptoms – there is no itching, burning, bleeding, pain or discharge that accompanies it. So, since the people who have it don’t know it, they can easily and unknowingly transmit it when they have unprotected intercourse. Fortunately, the body’s immune system usually attacks this infection quickly and eliminates it before it can cause any harm.
The Immune System and Risk of Infection
However, in some circumstances, the immune system has trouble eliminating the infection and it begins to cause the disorder known as dysplasia which is a precancerous change of the cervix. There are several factors that increase the risk of the infection to result in dysplasia. One risk factor is the person’s age. For some reason, women over the age of 30 have a bit more difficulty eradicating the infection and are thus, more susceptible to dysplasia. Another factor is the strain of the virus that is infecting the cervix. There are about 40 strains of HPV that typically infect the genital area and 13 of these are called high-risk strains. These high-risk strains are more likely to cause prolonged infections and the subsequent pre-cancerous and cancerous changes of the cervix. Other factors that increase the risk of dysplasia and cervical cancer include smoking, HIV, low folic acid levels in the bloodstream and a vaginal bacterial infection known as bacterial vaginosis.
Causative Relationship Between HPV, Cervical Dysplasia, and Cancer
The causative relationship between HPV infections resulting in cervical dysplasia and cancer is certain. The way that this happens is the HPV-infected cells on the surface of the cervix begin to grow and develop faster. This is because HPV affects certain cellular growth control mechanisms. As these cells begin to grow faster, they reach the surface of the cervix in a more immature state. This stage of the disease is called dysplasia and there are three stages of this – mild, moderate and severe dysplasia– that are determined by how much of the surface cell layer of the cervix is involved with the immature cells.
If this growth and development is allowed to continue without either the immune system stopping it or without medical intervention, these surface cervical cells may begin to invade the foundation upon which they grow called the basement membrane. Once they pass through this barrier, cervical cancer is present and it may begin to spread to other areas of the pelvis or to other areas of the body through the bloodstream or the lymphatic system. Fortunately, this process of progression from dysplasia to cancer is generally very slow and these changes probably take 5-15 years after the causative HPV infection occurs.
Degrees of Cervical Dysplasia
Here are representations of the differing degrees of dysplasia. Mild dysplasia consists of immature cells involving the inner third of the surface cellular layer. Moderate dysplasia involves two-thirds of its thickness and severe dysplasia is present when the entire cell layer is occupied by the dysplastic cells. Cervical cancer is present when the cells break through the basement membrane.
Pap Smears to Detect Cervical Dysplasia
Of course, no one ever wants to allow cancer to develop, so what can you do to detect dysplasia before it becomes cancer? The answer is to have a PAP smear performed at the appropriate interval that is determined by your doctor. The PAP smear detects dysplasia between 70 and 80% of the time and it is fairly accurate at determining the degree of severity. It can detect dysplasia because these immature cells tend to fall off of the cervix very easily. When a PAP smear is performed, it gathers a sample of the cells that are shedding from the surface of the cervix and then these cells are sent to a lab where they are examined under a microscope.
Dysplastic cells have distinct characteristics that make them look suspicious and when they are identified, the doctor will notify the patient that she needs additional testing to see where the dysplasia is located and how severe it is. This test is called colposcopy and involves a magnified view of the cervix after it is stained with vinegar which highlights abnormal tissue. If this is seen, a biopsy is performed that allows the doctor to determine the degree of severity of dysplasia.
Treatment for Cervical Dysplasia
The treatment of dysplasia is dependent upon these results. After decades of research, it has been determined that mild dysplasia has a tendency to regress spontaneously without any treatment whereas moderate and severe dysplasia have a greater tendency to progress toward becoming cancerous.
Therefore, if a patient has mild dysplasia, she will simply have PAP smears at more frequent intervals(q)to monitor for regression or worsening. If it regresses, which happens in the majority of episodes, PAP smears will be performed at their normal intervals once again. If it worsens, it is then treated in the same way that moderate and severe dysplasia are treated. Unfortunately, there are no medications available that treat dysplasia yet, so treatment currently consists of removal of the affected area of the cervix in order to eradicate the abnormality.
The most common excisional treatment is called a LEEP procedure which is typically done in the comfort of the doctor’s office. Occasionally, the dysplasia must be treated with a deeper excision known as a cone biopsy. This is done in the operating room. These treatments are very successful at eliminating dysplasia when its treatment is necessary.
Given the fact that HPV is so common, it is important to discuss the interventions that might prevent the infection altogether. The first step in prevention is to avoid having multiple sexual partners because each new partner represents an entirely new set of his or her past exposures. Another critical component of prevention is to have “safe sex” by always using a condom until a couple is in a mutually monogamous long-term relationship. This does not guarantee protection, but it is the best way to minimize genital HPV exposure.
A rather new and extremely important method of prevention is to receive the HPV vaccine if you are between the ages of 9 and 26. This vaccine prevents infection from nine of the most common cancer and wart-causing strains of HPV known as HPV. Although this vaccine provides fantastic protection, it is important to remember that there are over 30 other HPV strains for which they will not provide protection.
Education is Key in Prevention
Despite decades of attempts to educate people about these preventive measures, cervical dysplasia remains an incredibly common problem. That’s why PAP smears play such a vital role in women’s health. Since its development in 1927 by Dr. Papanikolau, the PAP smear’s ability to detect dyplasia and allow for its treatment has prevented millions of cases of cervical cancer and has saved millions of women’s lives in the process. So, when you are putting yourself through the uncomfortable process of sacrificing your modesty to undergo this test, be thankful that you have access to it because it is truly a test that has revolutionized women’s health for over 85 years.
Thanks for learning about this interesting topic. If you have any additional questions about cervical dysplasia or one of the HPV vaccines, please discuss these with Dr. McDyer or Dr. Suhrer during your visit. Schedule your annual pap smear today!